CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &

List Diagnosis Diagnosis Pedu

Female/61 YO 1. 1.1 - Bed rest RBS after
History Decrease Refrakt O2 on ventilator 10
Decreased of d of er Gastric lavage /8hour, minutes
If < 70
conscioussness Consious Hypogli if 1x clear, start fluid
Headache ness cemia diet 6 x 200 cc mg/dL
repeat
Low intake 1.2 HT IVFD NS 20 dpm until 3
Had Hypertension not emerg IVFD d10 % 16 dpm times
routinely controlled ency
If > 70
Physical Examination Source: NHS 2010 mg/dL 
GCS 1x1 on ventilator IVFD
BP 227/120 175/90 Glucose
10% 100
mmHg mL/hour
HR 120 bpm until
RR 32 tpm patient
T 37.2 C can eat

Workup Source:
RBS 9-59-147-246-135- NHS 2010
65-81-95-136-95 P. Edu:
Consume
food
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/61YO 2. 2.1 c Give IVFD D10 % as GCS,
History Hypoglic insulin above, previously RBG/hou
emia oma patient was given d40 r
Decreased of (resolved % 50 ml in the first
conscioussness /improve 2.3 Drug step, and then
Headache ment) induce continued with IVFD
Low intake d ?? D10%
Had Hypertension not
routinely controlled

Physical Examination
GCS 1x1 on ventilator
BP 227/120 175/90
mmHg
HR 120 bpm
RR 32 tpm
T 37.2 C

Workup
RBS 9-59-147-246-135-
65-81-95-136-95
 POMR
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/61 YO 3. HT - - Drip nicardipin 0,5 Blood
History emergen mcg/kgBW/minute Pressure
Decreased of cy (tappering Off)
conscioussness (improve Peroral : planning P. Edu:
Headache ment) valsartan 1x80 mg Low salt
Had Hypertension not diet
routinely controlled routine
control
Physical Examination
GCS 1x1 on ventilator
BP 227/120
175/90117/77
mmHg
HR 120 bpm
RR 32 tpm
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/61 YO 4.HF 4.1 HHD Echocardio Bed rest Shortnes
History Stage C graphy Low salt diet s of
Had hypertension since 2 FC III Controlled the blood Breath
years ago not routinely
controlled
pressure ECG
SOB when doing heavy Treat the underlyng record
activties disease PEdu:
Disease
Nausea in 2 weeks Underlyi
Physical Examination ng
BP 227/120 175/90 disease
HR 120 bpm Treatme
Cor cardiomegaly nt
Workup
ECG Sinus tachycardia, Prognosi
LVH s
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/61 YO 5. 5.1 PUD - Insert NGT Subjective
History Hemate 5.2 Gastric lavage /8 Vital Sign,
No history of nausea mesis Gastriti hours, when 1x Bleeding
and vomiting before s clear, start fluid diet sign
Physical Examination erosive 6x 200 cc
NGT : coffee ground Drip lansoprazole 6 PEdu:
appeareance mg/ hour Disease
Underlyin
Laboratory g disease
Faal Hemostatic within Treatmen
normal line t
Prognosis
 CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/61 YO 6. Tinea KOH Ketokonazole cream Plague
History corporis staining ue healing

PEdu:
Physical Examination Sanitaion
Status localis : plaque and
hypepigmentasi, hygiene
squamous, distributed
at bilateral regio
humerus D?S

Workup